8.1 Engorgement
Breast fullness
Secretory activation (lactogenesis II) occurs biochemically at about 30 - 40 hours postpartum.1 The clinical onset is heralded by the maternal experience of 'the milk coming-in' and the breasts making a copious volume of milk. Across studies the average timing of this is reported to be 50 to 73 hours postpartum, with wide individual variation (1hr to 148 hrs).2
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![]() | Why does this happen?Several hormonal and biochemical changes occur which contribute to copious milk production: 3
Review this in Topic 4.0 | ![]() |
Signs and Symptoms
Women report knowing their milk is 'in' by the following cues:
- breast fullness
- milk leakage
- physical appearance of the milk
- breast tingling
- change in infant cues.
Engorgement
...the swelling and distension of the breast, usually in the early days of initiation of lactation, caused by vascular dilatation as well as the arrival of the early milk.5,
Breast engorgement is not an inevitable part of early lactation.
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![]() | Why does this happen?Hormonal and biochemical changes combine to create a 'traffic jam' in the breast.
There is a combination of
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If normal breast fullness progresses to engorgement the signs and symptoms include:
- swollen breasts; tight, shiny skin
- generalized redness of both breasts
- mild to severe pain
- increased heat of both breasts
- difficulty latching baby effectively and achieving milk removal
- mild pyrexia (fever)
Prevention

Engorgement.
© S.Cox, IBCLC
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![]() | ![]() Don't be fooledBreast fullness is normal. Engorgement is a warning sign. Engorged, large breasts are not a sign of a good milk supply. It indicates that breastfeeding practices are suboptimal and proactive management is required to retrieve normality. Breast engorgement is preventable in most cases. | ![]() |
Milk engorgement can occur at any point in the progression of breastfeeding. The cause is milk stasis from oversupply, inadequate drainage and long gaps between feeds rather than reasons of interstitial odema, and increased venous congestion.
Unresolved or repeated episodes of engorgement risks blocked ducts, mastitis and low supply.
Severe engorgement (initial or with established lactation) begins the process of involution of the breast due to poor milk drainage. The mother will progress from painful engorgement with perceived adequate/excessive amounts of milk, to an inadequate supply. Poor milk supply and nipple damage have been identified by mothers as reasons for premature weaning of their babies.14
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![]() Workbook Activity 8.1Complete Activity 8.1 in your workbook. |
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Clinical Management
Frequent, effective removal of milk from the breast until it is comfortable is the mainstay of management.
- Encourage the mother to breastfeed her baby often. If baby feeding well, but breasts still uncomfortably tight, expressing enough to maintain comfort is essential. This can be done after and between feeds as often as is necessary.
- Ensure baby is latched on to breast well. If breasts are very firm but there is no areolar edema, hand expressing for a few minutes to soften the nipple/areola area may be required. Re-latching the baby after suckling for several minutes will result in an even deeper latch.
- Allow the baby to feed as long as he will on one side to optimize drainage. Firm, but gentle massage of lumpy areas while baby feeds helps drainage. Allow the other breast to drip freely. If baby doesn't want the second side, express enough milk to make that breast comfortable. Repeat this process each feed.
- When breasts are particularly full it can be effective to stimulate a milk ejection by soft massage or short-time application of a warm compress. Then apply gentle compression anywhere on the breast with the palm of the hand - this gentle pressure may help the milk flow freely from the nipple without having to hand express or use a pump which may be too uncomfortable.
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![]() | ![]() Will expressing increase milk supply?The emphasis is on frequent removal of milk to prevent milk stasis.
Milk volume is increasing daily until peak milk volume between 2-3 weeks post-partum. Extra expressing and breastfeeding will promote better breast drainage but it will not increase milk volume further. Reassure the mother that this management will assist faster resolution of her engorgement. Failure to diligently attend to these strategies will prolong the discomfort, initiate involution and risk a resultant low supply. | ![]() |
- Reduce tissue swelling
- A Cochrane Review of management of breast engorgement 15 examined trials of breast engorgement treatments:
- There is no difference between treatment with cold packs or cabbage leaves. Both were equally effective in relieving pain but there was no strong evidence that interventions resolved symptoms faster than with no treatment.
- Acupuncture gave greater improvement in symptoms in the days immediately after the treatment.
- The underlying principle is the use of cold to initiate vasoconstriction to decrease venous congestion and help reduce interstitial oedema.
- Depending on degree of engorgement, the cold compresses may need to be replaced frequently (e.g. 20 mins on, 20 mins off and repeat several times)
- Apply cold compresses to both breasts immediately after breastfeeding.
- Certain non-steroidal anti-inflammatory drugs are very effective. 15
- A Cochrane Review of management of breast engorgement 15 examined trials of breast engorgement treatments:
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![]() | ![]() Heat or cold?Heat increases blood flow to the breast and movement of fluid into the tissues to further exacerbate the engorgement.17 Avoid standing under a hot shower or soaking the breasts in warm water during this period of engorgement.
Mothers usually prefer the feeling of cold on their hot breasts, but it is important to individualise your management and be responsive if a mother finds this to be unpleasant. | ![]() |
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![]() Workbook Activity 8.2Complete Activity 8.2 in your workbook. |
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![]() Unit ActivityRevise your unit's policy on the management of engorgement. Develop a teaching plan for a 15-minute educational session you could lead on the prevention and management of engorgement for your colleagues. |
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Areolar oedema/edema
When areolar edema is present latching the baby onto the breast for effective breastfeeding is impossible. Methods have been described to assist the movement of this interstitial fluid to make latching possible. 10,8
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![]() | ![]() Read this excellent practical articleClick on the icon on the left to be taken to a description of Reverse Pressure Softening for the treatment of areolar edema. Print the paper for filing in your Workbook. Share this paper with your colleagues who may be working with women experiencing this type of engorgement. Ask the mothers about their feelings of the usefulness of this technique. When you are proficient at it you will be able to describe its application over the phone to mothers in difficulty at home. | ![]() |
Additional strategies include
- lie mother on her back and massage the breast away from the nipple, towards the axilla; aiding lymphatic drainage
- baby has to be ready to feed immediately after massage because the fluid will return very quickly
- hand express if baby not available to suckle. DO NOT use a breast pump ... this increases the edema.
What should I remember?
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Self-test quiz
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Notes
- # Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships
- # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
- # Pang WW et al. (2007) Initiation of human lactation: secretory differentiation and secretory activation.
- # Neville MC et al. (1991) Studies in human lactation: Milk volume and nutrient composition during weaning and lactogenesis
- # Lawrence R (2010) A Breastfeeding guide for the Medical Profession
- # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
- # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
- # Miller V et al. (2004) Treating Postpartum Breast Edema With Areolar Compression
- # Hunter D (2004) Oedema and its impact on breastfeeding outcome: Assessment and management of the mother and her breastfeeding baby during the postpartum period.
- # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement
- # Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention
- # Academy of Breastfeeding Medicine (2009) Clinical Protocol #20: Engorgement
- # Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic
- # Wight NE (2001) Management of common breastfeeding issues
- # Mangesi L et al. (2010) Treatments for breast engorgement during lactation.
- # McLachlan Z et al. (1993) Ultrasound treatment for breast engorgement: A randomised, double-blind trial
- # Robson BA (1990) Breast engorgement in breastfeeding women